Regional Overview 2.3 Western Europe

Regional Overview 2.3 Western Europe

61

Regional Overview 2.3 Western Europe

62

Global State of Harm Reduction 2018

Table 2.3.1: Epidemiology of HIV and viral hepatitis, and harm reduction responses in Western Europe

Country/ territory with reported injecting drug use

People who inject drugs[1]a

Andorra

Austria

Belgiumf Cyprus Denmark

Finland France Germany Greece Iceland Irelandv Italy Liechtenstein Luxembourg Malta Monaco Netherlands Norway Portugal San Marino Spainaf Sweden Switzerland Turkey United Kingdom

nk 12,00017,000[3] 23,828

126 nk

15,611i 108,607lm

nk 4,173

nk 1,151[3] w

nk nk 1,467y 688[3]z nk 840aa 8,888ad 13,162 nk 11,048ag 8,021ah 42,000[3]ak 12,733am[27] 122,894ap

nk ? not known

HIV prevalence among people

who inject drugs(%)[1]a

nk

4

10.5 1.5 nk 1.2j 4.7n 1.6-9.1r 5.1 nk 6 28.8 nk 13.2 1.2 nk 3.8ab 1.5 14.3 nk 31.5 7.4ai 10-12[25] nk 0.9aq

Hepatitis C (antiHCV) prevalence among people

who inject drugs(%)[1]a

Hepatitis B (anti-HBsAg) prevalence among people who inject drugs(%)[1]a

NSPb[1]

Harm reduction response

OSTc[1,2]

Peerdistribution of naloxone

DCRsc

nk

nk

nk

nk

x

x

38

4.4e

39

(B, M,O)

x

x

22 43.3 52.5h

74k 63.8o 62.6-73s 63.5 45[16] 41.5 56.6

nk nk 46.3 nk 57 nk 82.2 nk 66.5 96.8aj 42.1[25]al 39.8an 51-58[28,29]ar

5.6 1.5 nk

nk 0.81p 0.4-1.2t 1.6

nk 0.5 nk nk nk nk nk 0ac 0.9ae 2 nk 10.5 nk nk 3.9ao 0.4as

116 2

53 509

u 13 [16]

66[18]

nk 11 8 nk 175 51 2,099 nk 838 10

x 606at

(B, H,M) (B, O)[9] (B, H,M)

(B, M,O) (B, M) (B, H,M,O) (B, M)

[16] (B, M) (B, M,O)

nk (B, M,O) (B, M)[20]

nk (B, H,M,O)

(B, M) (B, M)

nk (B, M) (B, M)[24] (B, H,M,O) (B, M,O) (B, H,M,O)

x[4] x [10]

x xq[12] x[15]

x x xx[17] [18] x x x x x [22] x x x x x x au[31,32]

1g[8] x

5[11]

x 2[13] 24[14,15]

x x x x x 1[19] x x 24[21] 2[22] x x 16[23] x 14[26] x x

a Unless otherwise stated, data is from 2016. b All operational needle and syringe exchange programme (NSP) sites, including fixed

sites, vending machines and mobile NSPs operating from a vehicle or through outreach workers. (P) = pharmacy availability. c Opioid substitution therapy (OST), including methadone (M), buprenorphine (B), (H) medical heroin (diamorphine) and any other form (O) such as morphine and codeine. Figures for the number of sites are often not available in Western Europe due to a variety of service providers, which includes general practitioners. d Drug consumption rooms, also known as supervised injecting sites. e Based on subnational data from 2016. f People who inject drugs population estimate refers to lifetime injecting drug use and is based on national data from 2015. Infectious disease prevalence estimates based on subnational data from the Flemish community from 2015. g One drug consumption room operates in Li?ge with the approval of local government, though no national legislation permits such facilities.[5-7] h Year of estimate: 2008. i Year of estimate: 2012. j Based on subnational data from 2014. k Year of estimate: 2014. l Derived from treatment data based on self-reported injecting in the last three months. m Year of estimate: 2015. n Year of estimate: 2015. o Based on subnational data from 2011. p Based on subnational data from 2011. q While take-home naloxone is available in France, it can only be acquired with a personal prescription. r Based on subnational data from 2013-2014. s Based on subnational data from 2013-2014. t Based on subnational data from 2013-2014. u A total of 172 syringe dispensing machines operate in Germany, but the total number of NSPs is unavailable.[14,15]

v Year of estimates: 2010. w Year of estimate: 2015. x While take-home naloxone is available in Ireland, it can only be acquired with a person-

al prescription. y Year of estimate: 2015. z Year of estimate: 2015. aa Year of estimate: 2015. ab Based on subnational data. ac Based on subnational data. ad Year of estimate: 2015. ae Based on subnational data from 2015. af Year of estimates: 2015. ag Estimate derived from treatment data and relates to people reporting injecting in past

year. ah Years of estimate: 2008-2011. ai Based on subnational data from 2013. aj Based on subnational data from 2013. ak Year of estimate: 2015. al Year of estimate: 2011. am Based on a subnational estimate and number of high-risk opioid users, including but

not exclusively people who inject drugs. an Year of estimate: 2015. ao Year of estimate: 2015. ap Years of estimate: 2004-2011. aq Based on data from England and Wales only. ar Hepatitis C prevalence among people who inject drugs is 51% in England, Wales and

Northern Ireland, and 58% in Scotland. as Based on data from England, Northern Ireland and Wales only. at This figure does not include NSPs in England due to a lack of national data. au In the United Kingdom, peer-distribution of naloxone is limited to a small number of

projects.

Map 2.3.1: Availability of harm reduction services

Regional Overview 2.3 Western Europe

63

ICELAND

IRELAND

DENMARK

NALOXONE

NETHERLANDS

BELGIUM

UK

NALOXONE

NORWAY SWEDEN

NALOXONE

FINLAND

GERMANY

LUXEMBOURG

FRANCE

AUSTRIA ITALY

LIECHTENSTEIN SWITZERLAND

SAN MARINO

NALOXONE

MONACO

PORTUGAL

SPAIN

Both NSP and OST available OST only NSP only Neither available Not Known DCR available NALOXONE Peer-distribution of naloxone

ANDORRA

MALTA

GREECE

TURKEY

CYPRUS

64

Global State of Harm Reduction 2018

Harm reduction in Western Europe

Overview

The state of harm reduction in Western Europe has remained largely stable since the Global State of Harm Reduction last reported in 2016. From a global perspective, the region has an extensive harm reduction response to illicit drug use, with a wide range of services adapted to the needs of people who inject drugs operating in almost all countries. Despite this, there remains room for improvement.

As reported in 2016, opioid substitution therapy (OST) is available in all countries in Western Europe for which there is data on harm reduction services, and needle and syringe programmes (NSPs) are available in every country except Turkey. In this respect, Western Europe is one of the regions in the world with the widest availability of these key harm reduction services. Within countries, experiences have varied. In Spain and the Netherlands, the number of syringes distributed has reduced since 2016 in line with decreases in the population of people who inject drugs in those countries,[32,33] while elsewhere in the region (for example in Ireland and Sweden) programmes have been expanded and more syringes have been distributed over the period.[24,34] Expansions of existing NSP programmes have also incorporated the increasing use of syringe dispensing machines, for example in Cyprus and the United Kingdom.[9,35,36]

A rising concern in Western Europe is overdose deaths, which have increased in number since 2016.[1] An estimated 84% of overdose deaths in the region involved opioids in 2016, and almost two thirds occurred in Germany, Turkey and the United Kingdom.[1,37] As part of the public health response to this, 89 drug consumption rooms (DCRs) exist in Western Europe, with Belgium opening its first facility in 2018. However, at the time of publication no DCRs existed in the UK. Naloxone, an opioid antagonist that can reverse the effects of overdose, is available to medical personnel in most countries in the region. However, take-home naloxone, in accordance with World Health Organization recommendations, is only available in eight countries (Denmark, France, Germany, Ireland, Italy, Norway, Spain and the UK), and peer-distribution networks are only permitted in four (Denmark, Italy, Norway and the UK). An emerging phenomenon of fentanyl presence in drugrelated deaths in England and Wales makes overdose responses even more vital, and is a development that must be monitored closely across the region.[38]

Interventions targeted at the use of amphetaminetype stimulants (ATS) and new psychoactive substances (NPS) form an increasing proportion of harm reduction services in Western Europe.

This includes needle and syringe programmes and DCRs, which in some locations provide facilities specifically for inhaled or injected consumption of ATS.[23,39] On-site drug-checking services at parties and festivals have expanded greatly since 2016, and are now available in at least seven countries (France, Italy, Luxembourg, the Netherlands, Portugal, Spain, Switzerland and the UK) to address harms caused by high-purity and adulterated substances. However, in many countries drug-checking services continue to suffer from a lack of legal and financial support from the state. Beyond drug-checking, the harm reduction response to new psychoactive substances, such as synthetic cannabinoids and synthetic cathinones, remains stunted.

Controlling infectious diseases among people who inject drugs remains a primary driver of harm reduction in the region. Unrestricted universal access to direct-acting antivirals for hepatitis C is only available in 10 out of 25 countries (see viral hepatitis section below), with most countries placing limitations on access based on either disease stage or injecting drug use.[13,18,23,40,41] Incidence of HIV among people who inject drugs halved between 2007 and 2016, though injecting drug use was still responsible for 5% of new HIV infections in the European Union (EU) in 2016.[37] People who inject drugs continue to face formal and informal barriers to testing and treatment for blood-borne diseases. Stigma, self-stigma and criminalisation all contribute to lower testing and access to treatment among people who inject drugs than the general population[18,42], and migrants, women and people in rural areas are reported to face compounded barriers.[15,43]

The policy environment has continued to progress gradually in favour of harm reduction. At least 17 of the 25 countries in the region have policy documents supportive of harm reduction, and the EU has renewed and expanded its commitment to harm reduction through the Action Plan on Drugs 2017-2020.[44] Perhaps the most significant development in the region was in Italy, where harm reduction programmes were for the first time included in the Livelli Essenziali di Assistenza, the package of basic services that must be guaranteed across the country.[18] While policy has progressed in the region, funding for harm reduction remains a key concern. The funding landscape varies across the continent, from near-crisis in Greece to sustainable and sufficient investment in harm reduction in the Netherlands.[45] In all countries of Western Europe, however, the transparency of state investment in harm reduction is insufficient or poor, with investment rarely disaggregated from other

Regional Overview 2.3 Western Europe

65

spending.[45] Civil society organisations across the region have warned that the sustainability of harm reduction services and funding remains vulnerable to changes in the political make-up of national and local governments.[18,45]

Developments in harm reduction implementation

Needle and syringe programmes (NSPs)

The number of countries in Western Europe in which NSPs operate is unchanged since the Global State of Harm Reduction 2016, with services available in all countries except Turkey (and no data on Andorra, Liechtenstein, Monaco and San Marino). However, individual countries in the region have experienced both increases and decreases in availability and coverage.

Austria, Belgium, Finland, Ireland, Luxembourg, Portugal and Sweden have all seen increases in the number of syringes distributed over recent years.[24,34,40,46-49] In Sweden, low threshold NSPs now operate in eight council areas, compared with three in 2015, and changes in legislation effective from March 2017 have facilitated the establishment of new NSPs.[24] In Luxembourg, a new mobile outreach service was launched in November 2017.[49] In Ireland, NSPs operate through fixed-site facilities, outreach services and pharmacies, where packs are distributed containing injecting equipment for between three and 10 injections, with an average of 1,614 people using the services per month.[34] Since 2016, syringe dispensing machines have been introduced in Cyprus, meaning that they are now available in at least six countries in the region (Cyprus, Denmark, France, Germany, Luxembourg and the United Kingdom).[9,11,15,36,49,50] Though there has been an increase in the number of NSPs operating in the Flemish areas of Belgium, and from 2014 to 2016 the total number of syringes distributed annually increased to 1.1 million, 80% of people who inject drugs in the country claim to know other people who use drugs who do not use NSPs.[47] This is a clear indication that, despite successes in increasing coverage, more outreach work is necessary to ensure that all people who inject drugs have access to sterile injecting equipment.

In other countries in the region, distribution of needles and syringes has decreased over recent years. In some cases, such as in Spain and the Netherlands, this is the continuation of a long-term trend attributed to a reduction in heroin use and

injection in general, as well as the success of harm reduction programmes.[32,33] Due to budget cuts in Italy, the number of harm reduction services offering NSPs fell from 106 in 2012 to 66 in 2015, a negative trend that civil society organisations expect will continue unless the new Livelli Essenziali di Assistenza is implemented properly.[18,51] Though the proportion of people sharing needles in England, Wales and Northern Ireland appears to have fallen from 23% in 2006 to 17% in 2016, a survey of people who inject drugs in the United Kingdom found that only 46% indicated that service provision was adequate in 2016.[28,30] Civil society organisations in the UK report that there has been no government effort to expand coverage to address this deficiency.[30,52]

A recurrent issue in the implementation of NSPs in Western Europe is the geographical distribution of services within countries. For example, six of Italy's 20 regions have no NSPs (though civil society organisations expect this to improve over the coming years), and coverage is decreasing in southern Portugal even while it increases elsewhere in the country.[18,42,51] There are no NSPs in the Germanspeaking part of Belgium.[47] In Austria, Greece and Spain, people who use drugs living in rural areas have difficulty accessing harm reduction services that are primarily located in provincial capitals and other large cities.[23,46,53] In Berlin and North-Rhine Westphalia in Germany, syringe dispensing machines have been effective in providing access to these populations,[14,15] a model which could be introduced elsewhere in Western Europe.

A further concern is whether current NSPs are meeting the needs of all groups of people who inject drugs. For example, in Portugal and the United Kingdom, it is unclear whether the needs of people who inject performance- and image-enhancing drugs are being met in harm reduction services focused on people who inject opioids.[31,42] Similarly, men who have sex with men are forming an increasing proportion of people who inject drugs (up from 4.4% in the United Kingdom in 2006 to 7.9% in 2016) and have a distinct profile from other people who inject drugs; for example, being more likely to inject methamphetamines or ketamine, and more likely to share syringes.[28] In England and Wales, injection of crack cocaine is also an increasing phenomenon, up from being reported by 35% of people who inject drugs in 2006 to 53% in 2016.[28] Some efforts have been made to create services for specific groups of people who inject drugs; for example, an NSP for women who inject drugs in Malta.[20] Also of note, in 2015 a Health Service Executive Ireland review recommended that the contents of injection packs be better adapted to the needs of people

66

Global State of Harm Reduction 2018

using the equipment by including a wider range of paraphernalia, such as sterile spoons, filters and foil.[34,54]

Opioid substitution therapy (OST)

In the European Union and Norway there were 636,000 people receiving OST in 2016, corresponding to approximately half of people who are dependent on opioids in these countries.[37] This is a small decrease of 1.2% since 2016 and a decrease of 10% since 2010.[55] Coverage in most countries has been largely stable over the last two years, with no serious contractions or expansions in access.

Methadone remains the most commonly prescribed medication for OST across the region, and is especially dominant in outreach services such as those in Portugal.[42] A buprenorphine-naloxone combination (sold under the brand name Suboxone) forms a growing proportion of OST in Germany, Italy and Spain, and is the main substitution medicine in Finland. However, the cost to the patient is higher in Spain and it is only available in high-threshold facilities in Portugal.[23,42] In Germany and Switzerland, slow-release morphine is also available for OST. [14,15,26,39,56,57]

Heroin-assisted therapy (HAT), the prescription of medical heroin (diamorphine) for OST, continues to be available in six countries in the region: Belgium, Denmark, Germany, the Netherlands, Switzerland and the United Kingdom.[2,14] A pilot programme using diamorphine also started recently in Luxembourg[19] and in 2018 the Norwegian government announced a diamorphine trial that will begin in 2020.[58] Implementation varies by country, but HAT is generally reserved, as in Denmark, for people who use opioids for whom other substitution therapies have not been successful.[2,11] Studies and trials in Belgium, as well as elsewhere in the region and the world, have found that HAT can be highly successful among this population in that it produces greater adherence than other forms of OST, reduces street heroin use and criminal involvement, and leads to better health outcomes.[59] In the UK, HAT remains available, but civil society organisations report that there are fewer prescribing doctors than in 2012, and that services are reluctant to prescribe diamorphine because of the high cost.[31] In Switzerland, the availability of HAT in the Frenchspeaking region is poor, and there is no HAT in the Italian-speaking region.[26]

A key barrier to the successful implementation of OST programmes is that they often continue to target abstinence from illicit drug use rather than harm reduction. Even low-threshold OST programmes in

Luxembourg require abstinence from all illicit drugs while undergoing therapy, as do higher-threshold services in Portugal.[19,42] On the other hand, new regulations in Germany (driven by harm reduction organisations and people who use drugs) have changed the official objective of OST from striving for abstinence from all illegal substances to striving for abstinence from heroin only.[14] While this is still problematic for some people who use drugs, it represents a significant step in the right direction. In the United Kingdom, civil society organisations report that some OST clients are being forced to reduce their dosage to a sub-optimal level, and can be subject to drug testing.[30,31] This appears to be the result of a lack of funding combined with clinical guidelines and key performance indicators that lack commitment to a harm reduction framework.[30,31] A 2018 United Kingdom government report into drugrelated deaths indicated that the role of sub-optimal doses of methadone in opioid overdose deaths requires greater attention and research.[60]

Migrants also frequently experience difficulties in accessing OST, as reported in Belgium and Switzerland.[4,57] Conversely, OST was included in new guidelines on basic medical care in Italy in 2017, ensuring that it is officially available to all in the country, including non-citizens and undocumented migrants (though civil society organisations report some issues in access for these populations in practice).[18] In Germany, people living in rural areas are often forced to travel 30 to 50km in order to access OST due to the low number of physicians who apply to be authorised to prescribe substitution medication. A 2017 revision of the legal framework seeks to address this issue.[14] Further barriers to accessing OST in the region include age restrictions, limited opening hours and long waiting lists, all of which contribute to limiting the proportion of people who inject drugs able to access OST.[4,14,31,42] A 2018 Freedom of Information request to the Northern Irish government found that the average waiting time for OST in Belfast is 29 weeks.[61] In particular, women are reported to face more restrictions than men, including a lack of childcare at OST services, hostile and judgemental attitudes from health professionals, and an absence of women-specific services.[31,42,62]

A Swedish study published in 2017 found that people who have received OST are four times more likely to die from a drug-related death during periods away from treatment than while on treatment.[63] This emphasises the need to reduce barriers to OST adherence, such as stigma and the requirement to abstain from illegal drugs.

Regional Overview 2.3 Western Europe

67

Amphetamine-type stimulants (ATS) and new psychoactive substances (NPS)

Use of ATS in Western Europe has stabilised over the last two years following a decline since the early 2000s.[37] However, consumption varies considerably between countries in the region. For example, last-year prevalence of MDMA use among people aged 15-34 ranges from 0.2% in Portugal to 7.4% in the Netherlands.[37] Evidence from across Europe suggests ATS are primarily used by young people (with a mean age of 23 years) in party contexts.[18,64]

As with ATS, prevalence of NPS use varies by country and substance. Synthetic cannabinoids, often referred to as "Spice," are the most prevalent category of NPS in Western Europe, with high prevalence reported in France, Germany, Spain, Sweden and the United Kingdom.[65] For example in 2016, prevalence of use among students in Germany was 6%.[65] The potential harms from synthetic cannabinoids vary considerably with the strength of particular strains. These can include severe seizures, psychosis and heart attacks, and there have been several outbreaks of fatal poisoning, including in Manchester in the United Kingdom in 2018.[65] The harm reduction response to synthetic cannabinoids in Western Europe appears to be limited to providing information on the potential risks of use, such as that provided by Release in the United Kingdom.[66]

NPS are also present in party contexts. In the Netherlands, almost one quarter of young adults in the nightlife scene have used 4-FA, a stimulant associated with around 8% of drug-related health incidents in the country.av[67] In Italy, 3.5% of people aged 15-19 have ever used an NPS, mostly hallucinogens such as DMT at psychedelic trance parties.[18] This figure increases to 11.9% when including synthetic cannabinoids.[18] Across the region, a significant barrier to data collection and harm reduction for NPS is that use is often unintentional or people do not know what they are taking.[18,23,26,42] For example, the Be Aware On Night Pleasure Safety (BAONPS) drug-checking project has found that one third of NPS samples collected in Italy do not contain what was expected.[18] This has been found to be a particular issue with online purchases.[18] For this reason, drug-checking services offer an opportunity to people who use these substances to ensure they are aware of the contents and the potential harms they may cause.

Drug-checking services operate in at least nine countries in the region: Austria, France, Italy, Luxembourg, the Netherlands, Portugal, Spain,

Switzerland and the United Kingdom. Services operated by civil society organisations have served people who use drugs in Italy for many years, and since 2016 now do so with support from public institutions in some regions.[18] In the region of Piedmont, drug-checking has been included as an essential public health service in regional guidelines.[18] The Loop in the UK and the Pipapo project in Luxembourg offer on-site drug-checking services at festivals,[31,68] while the Drug Information and Monitoring System (DIMS) in the Netherlands is a national network of permanent testing facilities that offers consumers the chance to check their drugs anonymously.[69] In Switzerland, on-site drug-checking services are now operated with local government approval at nightclubs and festivals in Basel, Bern, Z?rich and since 2018, Geneva.[26] In Bern and Z?rich, walk-in services are offered on a weekly and twiceweekly basis respectively.[70]

Drug-checking services offer harm reduction for both high-purity and highly adulterated substances, though the former category appears to be more prevalent in Western Europe. For example, DIMS has found that the average dose per MDMA pill increased 27% from 123mg in 2012 to 156mg in 2016.[69] The strongest pill checked by DIMS in 2016 contained 266mg of MDMA, more than twice the maximum dose recommended by harm reduction organisations.[69] In one year from 2015-2016, the average MDMA content of samples checked in Z?rich rose by 27% from 120mg to 152mg.[71] DIMS has found that common adulterants include substances such as PMMA, which can cause an overdose at lower doses than MDMA.[69]

Legal and regulatory issues related to the handling of illegal substances continue to be a barrier to drugchecking services. For example, the Danish national health board has declined to permit drug-testing services, pending evidence from the United Kingdom and the Netherlands.[72] Though legislation allowing for drug-checking exists in Portugal, it is restricted to on-site testing and samples cannot be removed to a laboratory for further checks.[42] The geographically isolated nature of some festivals with heavy ATS and NPS use in Portugal has also been identified as a barrier to harm reduction programmes.[42] A lack of state funding for drug-checking has also been highlighted as a major obstacle to carrying out these projects, for example in Italy and Portugal.[18,42]

In addition to drug-checking services, other harm reduction interventions exist in Western Europe to address ATS and NPS use. Informational projects run by civil society organisations or groups of people

av There were 456 health incidents related to 4-FA in 2016, two of which were fatal.[67]

68

Global State of Harm Reduction 2018

who use drugs operate in several countries to ensure people who use drugs are aware of the potential risks and best practices.[4,14,31] Ensuring that water and calm spaces are accessible at parties and festivals forms part of the harm reduction response in the Netherlands and elsewhere.[21] To reduce the harm caused by inhaling MDMA and cocaine, organisations in Italy provide "safer sniffing kits". These include paper straws to prevent nasal damage, chewing gum and sweets to prevent excessive teeth grinding, and water and fruit juice to prevent dehydration.[18]

Though routine data collection in Western Europe often does not differentiate between amphetamine and methamphetamine use, there is some evidence that methamphetamine use has increased over recent years in some populations in the region.[37] Civil society organisations in both the United Kingdom and the Netherlands report that there has been a rise in the prevalence of methamphetamine and NPS use among men who have sex with men, sometimes associated with use in sexual contexts.[30,67,73] While data on this relatively recent phenomenon (known as "chemsex") is generally unavailable and the extent of these practices may be overstated,[31,74,75] a sharp rise was observed in men who have sex with men accessing health services for issues related to methamphetamines, GHB and mephedrone from 2005-2012.[30,73] From the available data, it is impossible to determine if this is related to drug use in sexual contexts or other factors.[76] Nevertheless, there is a clear demand in the UK from patients in sexual health clinics for harm reduction measures associated with the use of these substances, which may include NSPs and other services adapted to the needs of this population.[77] For example, the Dean Street Clinic in London offers an NSP together with informal counselling and advice specifically tailored to men who have sex with men who use drugs in sexual contexts.[31,78]

Chem-Safe, a website operated from Spain by Energy Control since 2017, aims to provides online harm reduction information to men who have sex with men who use drugs in sexual contexts.[79,80] The anonymity and confidentiality provided by an online platform is considered particularly important, given the sensitive nature of the information and service users who may be stigmatised because of their sexual orientation, HIV status or drug use.[80] Despite early successes in accessing this population, ChemSafe currently has no ongoing financial support and relies on the uncompensated work of the project's coordinator.[80]

People who inject amphetamines are able to access NSPs and most drug consumption

rooms in the region. Furthermore, facilities in Germany, Switzerland and Catalonia, Spain specifically serve people who inhale drugs such as methamphetamines.[15,23,39] However, civil society organisations in Portugal and the United Kingdom report that an emphasis in harm reduction facilities on people who use opioids can discourage people who inject ATS from accessing them, indicating the need for tailored harm reduction services for people who use ATS.[31,42]

Cocaine remains the most commonly used illicit stimulant in Western Europe.[37] There appear to be marked differences in consumption patterns and behaviours between different populations of people who use cocaine in the region, particularly between those who use powder cocaine and those who use crack.[18,37] Most datasets in the region do not distinguish between crack and powder cocaine use, making the observation of trends in use of each form challenging.[37]

Harm reduction for cocaine use varies considerably according to differing patterns of use. For people who use powder cocaine recreationally, drugchecking services can have a significant impact in identifying high-purity and dangerously adulterated samples. Purity of cocaine has increased significantly in samples checked in Z?rich, with the average cocaine content rising from 41.7% in 2009 to 76.7% in 2016.[81] An increase in purity has also been observed in the Netherlands.[67] Harm reduction for crack use appears to be mostly absent from Western Europe, though innovations providing sterile inhalation equipment to prevent the spread of infectious diseases are being implemented in Ireland, in development in Spain and in demand in Portugal.[23,42,54,82] Portuguese civil society organisation GIRUGaia operates a harm reduction outreach programme in Porto providing clients, 90% of whom use crack, with legal support and assistance in attending court appointments.[42] The harm reduction response to crack use in Western Europe is significantly smaller than the response to opioid use, in part because of lower prevalence. The European Monitoring Centre for Drugs and Drug Addiction have highlighted the need for more research to establish best practices in harm reduction in this area.[83]

Overdose, overdose response and drug consumption rooms (DCRs)

According to data covering the European Union, Norway and Turkey, there were 9,138 overdose deaths in the region in 2016, approximately 84% of which involved opioids.[1] Drug-related deaths have steadily declined in some countries (such as Spain,

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download